Failure to Develop Baseline Care Plan for Use of Restraints and Bed Alarm
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted with diagnoses including epileptic seizures, dementia, and muscle weakness. Upon admission, physician orders were in place for bilateral padded upper half side rails and a bed alarm to address the resident's high risk for falls and generalized muscle weakness. Documentation showed that the resident was unable to make decisions, and assessments confirmed the use of these devices as part of the resident's care. However, review of the resident's records revealed that no baseline care plan was created to address the use of side rails and bed/pad alarms as required. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that a baseline care plan was not developed or implemented for the use of these devices. Facility policies required that a baseline care plan be created within 48 hours of admission, reflecting physician orders and assessments, but this was not done. The lack of a baseline care plan had the potential to delay the provision of essential healthcare services and affected the resident's well-being.